Psychiatry thread

“Psychiatry and neurology are inextricably linked. Psychiatry is neurology that we just don’t know yet.” -- Dr. Filley

The psychiatry thread started last semester during the CVPR block (cardiovascular, pulmonary, renal) and consisted of three brief lectures spaced throughout the block. Each lecture was then followed by an interview with a psychiatric patient. We split up into groups of eight students, each group led by a couple psychiatrists and/or psychologists who facilitated the interview and learning experience. One of the eight students then conducted the patient interview in front of everyone else.

At our level of training and experience (i.e. none), interviewing a patient by itself is enough to get the adrenaline flowing. But being observed and evaluated by both professors and our fellow classmates makes the experience that much more anxiety-provoking. I conducted an interview last semester with a patient who suffered from anxiety and depression related to a serious cardiovascular illness.

The psychiatry thread has continued into the neuroscience block. Each week, we cover a different condition or disorder. So far, we have interviewed patients with PTSD, autism, Parkinson's disease, chronic pain, bipolar disorder, and schizophrenia. Next week we're interviewing someone who is dealing with a substance use disorder.


I'm having a lot of fun with psychiatry. I have always been interested in the brain - how it works, and also what exactly goes wrong when it's not working so well. Learning about neurologic and psychiatric disorders in the classroom is good and all, but I really value this more clinically-oriented exposure to psychiatry. First, application of knowledge is always rewarding. Second, this psychiatry thread has encouraged me to appreciate on a personal level the impact that these diseases or disorders have on the individual.

I may or may not become a psychiatrist, but I have heard several times that every physician - regardless of specialty - practices psychiatry on some level.

Second year so far: Neuroscience block

So far, the second year of medical school has turned out to be remarkably like the first year: lots of lectures and didactic teaching. That's no surprise and is in fact quite the norm in medical education. We're currently in our neuroscience block, which I'm particularly enjoying. Just like last year when we had laboratory sessions coupled with hematology and microbiology coursework, the neuroscience block has offered some reprieve from the lecture hall with hands-on laboratory sessions to better learn neuroanatomy and synaptic transmission.

The neuroanatomy lab consisted of examining a whole brain, a hemisected brain (cut down the midline), and a brainstem+cerebellum, in order to identify important neuroanatomical structures. I was somewhat taken aback that this 3 hour session was the extent of our wet lab neuroanatomy exposure. Incidentally, a classmate of mine sent out the link to a website that uses magnetic resonance imaging (MRI) to teach neuroanatomy. It's pretty fun to play around with, and you can find it at www.headneckbrainspine.com.

The synaptic transmission lab made use of frog leg muscle fibers (connected to their motor neurons) and different drugs (curare, neostigmine) to demonstrate manipulations of signal transduction at the neuromuscular junction. When the motor neuron is electrically stimulated, you can record electrical responses from the frog muscle fiber - and even make it twitch, if the electrical stimulation is strong enough. Application of curare blocks the neurotransmitter acetylcholine, which is the means of communication between the motor neuron and muscle fiber. Neostigmine has the opposite effect, stimulating synaptic transmission by making acetylcholine more available at the junction between the motor neuron and muscle fiber.

I learn well by doing and by putting information in context, so I found these laboratory sessions fun and particularly helpful.

First day of school

School starts tomorrow! I've bought my textbooks and school supplies, I've cleaned off my desk, and I'm ready for the new school year. In fact, I'm so excited that I can't go to sleep. I take comfort in knowing that I can look for solidarity to a fair number of my classmates who feel the same way.

Second year kicks off with neuroscience and an interwoven psychiatry class. Fun!

Orienting the class of 2014

Orientation Week for the first-year medical students happened this past week. I had so much fun during orientation week last year (particularly at the retreat) that I decided to volunteer the last week of my last free Summer to help out as an orientation leader. This consisted mostly of herding the first-years from one place to the next and making sure that no one got lost or swallowed by a whale or something else equally as frightening. I was also there to answer whatever questions they threw at me and to otherwise calm them that medical school really isn't all that bad. It was a completely different experience for me than last year, when I was the one awash in anxiety of the Unknown.

As with last year, the two-day orientation retreat in the mountains was a ton of fun. For me, the highlights of the retreat were the team-building games, hiking in the mountains with a group of first-years, and the party that the orientation leaders threw for the first-years. I don't know when else I would have had the opportunity to get to know the class below me so well. Especially because it's so easy to become myopic in my own medical education, I feel that it was very important to meet my future colleagues.

They're a great group. I'm every bit impressed by them as by my own class, which speaks to what a great job the Admissions committee has done.

Taking stock of year one: Advice for incoming first-years

With the second year of medical school fast approaching, I've found myself reflecting on year one. What worked well for me and what didn't work so well? Having gone through that experience, what would I do differently if I could do it over again? What advice might I offer incoming first-year medical students? The following are five suggestions that I wish someone had given me before starting medical school. Everyone is unique, and there are many different learning styles out there, so these suggestions should be taken with that in mind.

1. Preparation for medical school: learn what you're going to learn before you start learning. I wish that someone had told me to buy First Aid for the USMLE Step 1 and flip through it during the Summer before starting medical school. Don't go crazy - don't try to memorize anything - rather, pay attention to the topics and types of knowledge for which you will eventually be held accountable. This may seem like overkill to a lot of people, but I know that I learn best when I can put what I'm trying to learn in a larger context.

2. Hone in on what's important. Medical school throws so much information at you that trying to memorize it all might literally drive you crazy. Instead, learn everything conceptually then identify what must be memorized. When it comes right down to it, the first two years of medical school are about cramming as much medical information as possible into your brain and demonstrating mastery of that knowledge by performing well on the Step 1 exam. First Aid is basically a road map of what a medical student needs to know in order to do well on that exam.

Another student a few classes ahead of me, offering advice to those following him just as I'm doing now, suggested reading the relevant sections of First Aid before each block then taking important class notes in the book so information is centralized. I didn't get that advice until after I finished my first year, but I plan on doing that during this coming year.

3. Anatomy: spend as much time in the cadaver lab as possible. I didn't do this at first, partly because it took me some time to adjust to the reality of dissecting a human cadaver. I noticed a substantial improvement of my understanding of the material when I prepared well prior to each dissection lab and when I spent time outside of dissection studying the anatomical structures. Study in a group and quiz each other.

4. Anatomy: Use multiple atlases. Everyone is infatuated with Netter's Atlas of Human Anatomy. The drawings are very well done, and they are helpful in showing anatomical relationships. So when I was shopping around for an atlas, I naturally bought Netter's. I found that it wasn't enough, though, and I ended up getting a second atlas: Grant's Atlas of Anatomy. It's drawings may not be nearly as pretty as Netter's, but Grant's includes a lot of additional information not found in Netter's. There are photographs, radiological images, and tables that organize complicated information like the fascial layers of the inguinal canal or the nerves and of the brachial plexus. My mind works well with tables.

I understand that not everyone is able to buy two atlases, but that shouldn't stop you from studying from more than one atlas. The library has many copies of both Netter's and Grant's. You can also borrow an atlas from a second-year, or study with a friend who has a different atlas than what you have. Bottom line: during anatomy, get your information from multiple sources.

5. Study the way you'll be tested. For the anatomy dissection lab, that means quizzing each other by tagging anatomical structures with pins. For everything beyond anatomy, that means answering USMLE-style questions. Subscribe to a question bank and use those questions to study during the last few days before an exam. It's most important that you do this during the CVPR block, since that block marks a significant shift toward more clinical material. However, I think doing this during the Molecules to Medicine, Blood and Lymph, and Disease and Defense blocks would have also proven helpful for me. I only started using a question bank to study during the renal section of CVPR and immediately wished that I had done so for the cardiovascular and pulmonary sections.

There are many question banks out there: USMLE World, Kaplan, USMLE Rx. Those are all subscription services. There is also a free question bank called Exam Master available through the Health Sciences library website, and also an up-and-coming free question bank called WikiTestPrep.

With so many question banks out there, what is the best approach? I am currently using USMLE World because many people I trust have told me that their questions are most comparable to those found on the real test. Also, for now, I only use this question bank in "tutor" mode, which means that my quizzes are not timed and that I get the benefit of reading explanations for each question. If you do start using a question bank to study during your first year, do yourself a favor and don't time yourself.

The long white coat

I was running around University Hospital today and bumped into a friend in the elevator. I knew him back when he was a lowly medical student with his short white coat, a fourth year. But today in the elevator, my friend who used to be a fourth year medical student was sporting a long white coat and looking very doctor-like. "I'm just an intern," he dodged. "It's a very steep learning curve."

It felt gratifying to see evidence of the progression: that medical students do actually graduate, get an M.D. after their name, and become an intern. That implies that interns do actually become residents and that residents in fact end their formal training to become full-fledged doctors (after a fellowship, maybe, but that's beside the point).

Such periodic reminders of progress is good for keeping up the morale.

Financial aid for the Summer

Here at the University of Colorado School of Medicine, financial aid for the first year only covers until classes end at the beginning of June. Students are not typically enrolled in course credits during the Summer between the first and second years of medical school. This gap of financial aid coverage is problematic for many medical students who otherwise would not be able to cover costs of living.

This year, though, a new mentored scholarly activity (MSA) Summer elective course has allowed the school to plug the gap of financial aid coverage. Everyone has to complete a MSA project as a graduation requirement, and some students choose to do the bulk of the work during this "last free Summer" between the first and second years. Such students now have the option of signing up for this MSA Summer elective. Since these credits count toward a graduation requirement, students enrolled in this course are eligible for financial aid.

This makes my life much easier.

Last day of classes!

I just finished my last class of my first year! Woo hoo! Six days from now, after I finish the renal (kidney) exam, I will officially be a second-year medical student. I'm ready for a break.

Donor Memorial Service

Last week, a donor memorial service was held for all the people who donated their bodies to medical education. This was a joint effort put on the the Schools of Medicine, Dentistry, Physician Assistants, and Physical Therapists, all of which use cadaver dissection to teach anatomy. The service was meant to give thanks to the donors and provide closure to their families, who it should be noted had to endure a prolonged period of mourning necessitated by the donation process.

The service also provided closure for students - for myself. It feels like such a long time ago when we were up in the cadaver dissection lab, but in actuality it has been just half a year. The experience of dissecting a human being strongly affected me, which is probably why I avoided even thinking about the memorial service until it was suddenly upon me.

The service was beautifully done thanks to a lot of hard work put into it by a lot of people, including our class vice-president Ramya.

One highlight of the service that I found most meaningful was listening to the families of donors talk about their loved ones who made such a selfless gift. Not just their words but their very presence - seeing that the woman whose body I dissected left behind family who mourned her passing - finally revealed the depth of her humanity that was so carefully and purposefully hidden from us during the actual dissection.

A second highlight of the service was the speech given by my friend and classmate Evelyn, who delivered it with such sincerity that I was literally moved to tears. I am sharing Evelyn's speech here (in full, with her permission) because it so accurately reflects my own experiences and sentiments.

Hello, my name is Evelyn. I’m a first year medical student and it is my honor to share some thoughts on behalf of my class in the School of Medicine. I’d like to start by telling you a couple of anecdotes, a window into the lab so to speak for a few moments, so that you might know how incredible and meaningful this experience was that your loved one gave us.

Our donors’ bodies are carefully prepared and protected and we newbies have some trepidation meeting them for the first time. There is a tradition that dissection starts on the torso, and the person’s head, hands and feet remain “covered” until last. These are considered the most human parts of the body and so most likely to engender discomfort initially for us dissectors.

Yet it felt strange to me to make incisions into this person’s body without having any sense of who she was. So I asked the professor if I could unbind her head to see her and meet her before we started. Happily, he agreed. It made all the difference in the world to me. Quiet and peaceful now, she still had a band-aid on her forehead, a bruise where she had bumped into something unexpectedly, a gold tooth and an ethnicity different from my own. Here were the signifiers of a story, her narrative, her life that I was now privileged to enter.

Since real names are protected, somehow the name Doris emerged as a fitting way for our group to relate to her as a person. As we worked on her back, she showed us see how all the muscles that help us stand and bend and twist are arranged, and under those the vertebrae with those discs between them that can slip out of position and trouble us.

Then we came to the inner sanctuary of the spine. We opened up the dura mater covering, and there lay the spinal cord, soft and glistening, with a perfectly formed cauda equina of nerve roots at the end. It took my breath away. It was simply beautiful and strangely seemed so alive.

A thought flashed into my mind that she hadn’t ever seen this and I caught myself literally almost tapping her on the shoulder to say, “Look at this – it’s amazing!” even though she couldn’t really lift her head and peer down her own back to see the beauty that was hers.

In the coming years, whenever I perform a spinal tap procedure to get clues from a patient’s fluid for diagnosis, I will remember to be careful about positioning the needle to protect these vitally important nerves that Doris showed us.

Another afternoon, I got to dissect her heart. The heart is superb and well sheltered inside a resilient pericardial pouch and layers of fatty tissue. Holding it in this shapeless state I felt like a sculptor facing a block of stone, before those patient hands chisel away to reveal a hidden treasure.

I settled in beside her head at the dissection table, and with her heart in my hands, carefully removed these protective layers to expose the shape we know - the four chambers and the coronary arteries that surround and nourish it with oxygen.

Then I opened it up to reveal the clever valves inside and stunning chordae tendineae – literally the “heart strings” - that tug on these valves to keep them tethered as they do their work, opening and closing to help the heart pump blood around the body.

For four hours, it was Doris and I in a world of our own, this silent teacher showing me a wondrous vista. As I worked, I realized that this heart beat inside her chest for more years that I’ve been alive and how it symbolically held her stories of love given and received. I wished I knew those too.

And to each of you sitting here today I would like to recognize the huge gift you too have given us. I lost my own mother a few months ago. She was somebody I was very close to. And I recall how protective I was of her handing her body over to the morticians for a mere two days to prepare her for the viewing and funeral. But all of you have waited graciously for up to two years for us to do our work before you could get your loved one back. I can only imagine what effect that has had on your grieving and that it perhaps delayed closure for you. I do hope today brings comfort to you and to that process.

And in this time that you have waited so patiently, have you ever wondered, what’s going on over there? How are they treating my mother, father, brother or sister? Are they being gentle and kind to them? Do they value what they’ve been given? Are they being respectful? Are they learning anything meaningful? And don’t they know that that’s my kin, and are they treating them well?

I’d like to tell you today that the answer is “Oh yes. Oh yes indeed – as if it was our own mother, father, brother, sister, grandmother, or grandfather.” On behalf of my class, we sincerely thank you and your loved one for the extraordinary gift you chose to give us.

As we go forward in our careers, the technical aspects of anatomy that we learned through your generosity will most assuredly come with us and help us be better doctors. But just as importantly, it has shaped us as people, who understand just how unique each person is on the inside as well as the outside and accordingly how they might respond differently to our treatments. And who know now just what it is to value, respect and care for those who can no longer speak for themselves.

The last time I saw Doris was to take the final lab exam in Anatomy. Arriving at her table was like meeting a friend. I smiled seeing her and at knowing so intimately the structure on her body that was pinned for identification. At the end of these ten weeks, she was helping me one last time in the exam. I brought flowers that day and placed them in her dissected hand. I felt it was the least I could do to honor her - and to say goodbye.

Wherever you are, thank you Doris - and thank you to each of you.

Pulmonology, Denver style

I have run across an unforeseen complication of going to medical school in Denver. We're in the middle of the pulmonology section right now, and it turns out that altitude has an effect on lung function. Who'd have thunk?

Up here in the mile-high city, the atmospheric pressure is appreciably lower (thinner air) than the atmospheric pressure at sea level. Since this has real-world clinical relevance, especially during our third and fourth year clinical rotations, we have to know - and will be tested on - physiological values based on Denver's altitude.


PB = Barometric pressure (Torr)
PiO2 = Partial pressure of oxygen in inspired air (Torr)
PaO2 = Partial pressure of oxygen in arterial blood (mm Hg)
PaCO2 = Partial pressure of CO2 in arterial blood (mm Hg)
SaO2 = Saturation of oxygen in arterial blood (%)
CaO2 = Oxygen concentration in arterial blood (mL O2 / 100 mL blood)
CaCO2 = CO2 concentration arterial blood (mL CO2 / 100 mL blood)
[HCO3-] = Bicarbonate concentration in arterial blood (mM)

To be fair, every medical student in America has to learn (hopefully) a set of equations that relate all of these terms with each other. That means a medical student in Boston or New York or Los Angeles should be able to derive these values for a patient at any given altitude. The catch is that, here in Denver, we have to memorize two sets of values. It's worth noting that most USMLE Step 1 board questions will likely specify that the patient is at sea level.